2 Contraception Induced abortionToday we will talk about 2 important topic, one is …the other is…First, let us see contraception. When I say this, I always say: family planning is tiny part in the textbook, only several pages, but I must say, it is more important than other part. A woman, she may not has any gynecology disease during her hole life, she may not want a baby, so she may not contact to obstetrics and gynecology, but, if she married, she must need family planning knowledge. Obgyn only relay to women, but family planning touch both women and man. So

3 How Pregnancy (Conception) OccursLet us come to …if we know how pregnancy occurs we could stop pregnancy, that is contraception.Egg cellsFallopine tubeSpermThe Fertilized eggIf we cut any step in this process, the pregnancy can be avoided.

4 Contraception mechanismPrevents ovulationThickens mucus at the cervix so sperm cannot pass throughChanges the environment of the uterus and fallopian tubes to prevent fertilization and to prevent implantation if fertilization occursBlock sperm from reaching the eggIf no egg cells, the sperm can do nothing.A fertilized egg likes a seed, the germination of seeds need very good conditions, such us fertile soil, sunshine, water and so on. If the environment of uterus is badly, the fertilized egg will not germinate.

6 controception methodsfemaleIUDHormonal contraceptionEmergency contraceptiveExternal contraceptionfemshieldspermicideSafe period contraceptionContraceptive vaccinessterilizationmalecondomsterilizationBy the way, I want say something about safe period contraception. Women’s period is affected by lots of factors, it is very hard to control safe period. So we always talk to our pationts: safe period contraception is the most unsafe contraception method. So stay away from this method.

7 So many…… Different shapes and different materials, plastic, metal.All kinds ofSo many……

8 Contraceptive methodsIud is most populer in china,Sterilization is wellcom in us, china, canada and beazil.In france most women like ocThis may be related to the cultural background, lifestyle, knowledge level etc.

9 Map of the use of various of contraception in China & developed countriesOral contraceptiveCondomSpermicideOthersMale sterilizationSubcutaneous implantationIUDFemale sterilizationVaginal barrierInjection/subcutaneous implantationSterilizationAlmost half women use IUD to contracept in china, while in developed countries only 15% use IUD.In developed countries most part contraception method is pill, while in china only 1.7% use it. I want say, chinese women have prejudice (or bias) to oral contraception. Even “white collar” women. They worry about the side effects of it. They want stay away from hormone. And I think this state will not change during 5-10 years. As we all know, change pepole’s mind is very hard, it needs long time.United Nations Department of Economic and Social Affairs Population Division: World contraceptive Use 2003

10 IUD（intrauterine device）Types of IUDInertia IUD（first generation）Active IUD（second generation）Copper-containing IUD（include nonsupport IUD）Medicine-containing IUDLNG-IUDIndomethacin-IUDFrom the aspect of material, IUD can be divided into two classes:Inertia /ɪ’nɚʃə / 惰性LNG is a kind of synthetic progestin. trade name called merina.Most IUD have there own shape, they keep their shape in uterus. But if IUD has no support or bracket, they called nonsupport IUD.铜套：copper sleeve,Fixed in the bottom of uterus.tie a knotAn IUD is a small, T-shaped plastic device that is wrapped in copper or contains hormones. The IUD is inserted into your uterus by your doctor. A plastic string tied to the end of the IUD hangs down through the cervix into the vagina. You can check that the IUD is in place by feeling for this string. The string is also used by your doctor to remove the IUD.Type of IUD:(1)Hormonal IUD. The hormonal IUD, such as Mirena, releases levonorgestrel, which is a form of the hormone progestin. The hormonal IUD appears to be slightly more effective at preventing pregnancy than the copper IUD. The hormonal IUD is effective for at least 5 years.(2)Copper IUD. The most commonly used IUD is the copper IUD (such as Paragard). Copper wire is wound around the stem of the T-shaped IUD. The copper IUD can stay in place for at least 10 years and is a highly effective form of contraception.

12 Mirena® The active ingredient: LevonorgestrelThickening of the cervical mucusIt prevents thickening of the womb liningPrevent ovulationIntrauterine ContraceptionHeavy Menstrual BleedingMirena®Womb [wum] 子宫Womb lining 子宫内膜Cavity 腔Mirena contains 52 mg of levonorgestrel. Initially, levonorgestrel is released at a rate of approximately 20 mcg/day. This rate decreases progressively to half that value after 5 years.Women who currently have or have had breast cancer, or have a suspicion of breast cancer, should not use hormonal contraception because breast cancer is a hormone-sensitive tumor.(1)Hormonal IUD. This IUD prevents fertilization by damaging or killing sperm and making the mucus in the cervix thick and sticky, so sperm can't get through to the uterus. It also keeps the lining of the uterus (endometrium) from growing very thick. This makes the lining a poor place for a fertilized egg to implant and grow. The hormones in this IUD also reduce menstrual bleeding and cramping.Other advantages of the hormonal IUD. Also, the hormonal IUD:(1)Reduces heavy menstrual bleeding by an average of 90% after the first few months of use.(2)Reduces menstrual bleeding and cramps(痛性痉挛，绞痛) and, in many women, eventually causes menstrual periods to stop altogether. In this case, not menstruating is not harmful.(3)May prevent endometrial hyperplasia or. endometrial cancer(4)May effectively relieve endometriosis and is less likely to cause side effects than high-dose progestin.3(5)Reduces the risk of ectopic pregnancy.(6)Does not cause weight gain.Disadvantage of hormonal IUD：in many women, it may causes menstrual periods to stop altogether. But this is not harmful to the user.

13 insert Time Contraindication: genital tract inflammation(1)Bi-Manual Exam: This is done to accurately determine the position, consistency, size, and mobility（活动性） of the uterus and identifies any tenderness, which might indicate infection.(2) Speculum, Stabilizing the Cervix: At this point, the doctor will hold open the vagina by using a speculum, which resembles a metal beak of a duck. The instrument is inserted into the vagina, then its blades are separated and held open by a special action device on the handle. Once this is accomplished, due to the importance of having a completely sterile environment to reduce the likelihood of infections, the cervix and the front and back wall of the vagina will be cleansed with an antiseptic solution.may apply a local anesthesia, such as 5 percent lidocaine gel, into the cervical canal to reduce discomfort.Your doctor will then use a tenaculum to help stabilize the cervix and keep it steady. The tenaculum is a long-handled, slender, instrument that is attached to the cervix to steady the uterus. Cervical anterior lip(3) Measuring the Uterus and Cervical Canal, Sound - Measuring the Uterus: This procedure reduces the risk of perforating the uterus (having the IUD puncture through), which usually occurs because the IUD is inserted too deeply or at the wrong angle. Your doctor will make sure to avoid any contact with the vagina or speculum blades. The uterine sound has a round tip at the end to help prevent perforation (puncturing the uterus).The uterine depth should between 5 and 9 cm as an IUD should not be inserted if the depth of the uterus is less than 5 cm.(4) Insertion of the IUD: After the sound is withdrawn, the doctor will prepare the IUD for insertion by removing it from its sterile packaging. Then, the arms of the IUD are bent back, and a tube (or slider) containing the IUD is inserted. The IUD is pushed into place, to the depth indicated by the sound, by a plunger in the tube. Once out of the tube and when the IUD is in the proper position in the uterus, the arms open into the "T" shape. Ring fork,The insertion of an IUD is usually uncomplicated. While many women may experience some discomfort, less than 5 percent of women will experience moderate to severe pain. Reactions, such as perspiring, vomiting, and fainting occur in 1 percent of women or less. These problems are generally brief and rarely require immediate IUD removal. Additionally, these reactions do not affect later IUD performance.Women who have never given birth, have had few births, or have had a long interval since last giving birth are most likely to experience these problem.(5) Once the IUD is in place, the tube, plunger, tenaculum, and speculum are then removed from the vagina. The intrauterine device will stay in place. The IUD will have strings attached to it that the doctor will leave intact. They hang down through the cervix into the vagina. At this point, the doctor will cut the ends of the strings but will allow about one to two inches to hang out of the cervix. The strings are not able to be seen from outside of the vagina but are long enough to be felt by a finger inserted in the vagina

15 1,3,6,12 month after the IUD insertion, to make sure it is in place. Follow-up1,3,6,12 month after the IUD insertion, to make sure it is in place.Once a year.Useful lifeThe copper IUD is approved for use for up to 10 years.The hormonal IUD is approved for use for up to 5 years.Your doctor may want to see you 1,3,6,12 month after the IUD insertion, to make sure it is in place.

16 IUD side effect and complicationEctopic prognancyEmbedmentCrackDownFall offPregnancy with IUDSide effectHeavy bleedingProlonged menstruationSpottingDischarge increasingAbdominal painEctopic Pregnancy /Intrauterine Pregnancy /Pelvic Inflammatory Disease (PID) /Irregular Bleeding and Amenorrhea /Embedment嵌入 /Perforation /pə:fə’reʃən] 穿孔/Expulsion 脱出/Ovarian Cysts /Risks of using an intrauterine device (IUD) include:(1)Menstrual problems. The copper IUD may increase menstrual bleeding or cramps. Women may also experience spotting between periods. The hormonal IUD may reduce menstrual cramps and bleeding.(2)Perforation. In 1 out of 1,000 women, the IUD will get stuck in or puncture (perforate) the uterus.1 Although perforation is rare, it almost always occurs during insertion. The IUD should be removed if the uterus has been perforated. To avoid this, tow steps are very important: one is bi-manual pelvic examination the other is measure of uterus depth.(3)Expulsion. About 2 to 10 out of 100 IUDs are pushed out (expelled) from the uterus into the vagina during the first year. This usually happens in the first few months of use. Expulsion is more likely when the IUD is inserted right after childbirth or in a woman who has not carried a pregnancy.1 When an IUD has been expelled, you are no longer protected against pregnancy.Disadvantages of IUDs include the high cost of insertion, no protection against STDs, and the need to be removed by a doctor.Disadvantages of the hormonal IUDThe hormonal IUD may cause noncancerous (benign) growths called ovarian cysts, which usually go away on their own.The hormonal IUD can cause hormonal side effects similar to those caused by oral contraceptives, such as breast tenderness, mood swings, headaches, and acne. This is rare. When side effects do happen, they usually go away after the first few months.

17 Takeout Reasons for an IUD Removal:A woman may have several reasons why she would want her IUD removed. These could include:Wanting to become pregnantContinual side effects that a woman can no longer tolerateThe development of an infectionA woman may just not like itwhen the IUD is no longer effectiveThe IUD Removal Procedure:Generally, expect some of the same initial steps performed during your IUD insertion, such as determining the position of the uterus.(1)Once the IUD strings are located, a qualified professional will remove the IUD by using forceps or clamps to securely grasp the strings and slowly pull out the IUD at a certain angle. The flexible arms of the IUD will fold up as the IUD slides through the opening of the cervix.(2)If the IUD is “O” shape or the string is disapper, you must use the hook.

19 Hormonal contraceptionContraceptive mechanismSuppression of ovulationChanges in the cervical mucus propertiesMorphologic and functional changes of endometrialChange the function of fallopian tube

20 Hormonal contraception --TypesOral contraceptiveslong-acting reversible contraceptives (LARC)Long-acting contraceptive injection (DMPA)Sustained release contraceptives (Norplant、Implanol)You will be given a local anesthetic and asked to lie on back, with non-dominant arm slightly bent at the elbow and turned outwards. The skin is stretched and a needle containing the implant is inserted directly under, and parallel to, the skin on the inside of upper arm. The implant will then remain under the skin when the needle is withdrawn

21 Available options for LARCLevonorgestrel (LNG) intrauterine system, effective for up to 5 yearsInjection, effective up to 12 weeksCopper intrauterine device (IUD), effective for up to 10 yearsImplants, effective for up to 3-7 years

28 What is emergency contraception?Emergency contraception is a way to prevent pregnancy if:Sex without using birth controlBirth control method failedforgot to take pill or get shotthe condom broke or came offdiaphragm slippedBe rapedIf you had sex without birth control, there is a chance that you could get pregnant.This is true even if you have not started having periods yet or you are getting close to menopause.You could also get pregnant if you used a birth control method that is not very reliable or if you didn't use it the right way.Using emergency contraception right away can prevent an unwanted pregnancy and keep you from worrying while you wait for your next period to start.Diaphragm：隔膜滑脱

29 What are the types of emergency contraception?Pillswork welldon't cost a lotusually easy to getCopper intrauterine device (IUD).works very wellbut it has to be inserted by a doctor

30 How does it work? Emergency contraception pills work bypreventing ovulationpreventing fertilizationpreventing implantation96% effectiveThe copper IUD may work bykilling sperm99% effectiveEmergency contraception hormones may prevent fertilization by stopping the ovary from releasing an egg (ovum).They also make the fallopian tubes less likely to move an egg toward the uterus.Emergency contraception is also thought to thin the lining of the uterus, or endometrium.The thickened endometrium is where a fertilized egg would normally implant and grow.

31 Does it cause side effects?Emergency contraception may cause some side effectsspotting or mild symptoms like those of birth control pillsnausea or vomitingsore breasts, fatigue, headache, belly pain, or dizzinessAn IUD may cause cramping and bleeding during the first few days after insertion

32 What else should you think about?Emergency contraception pills won't protect you for the rest of your cycle. Use your regular method of birth control, or use condoms.Unless you get an IUD, emergency contraception does not take the place of regular birth control. Find a good method of birth control you can use every time you have sex.Emergency contraception does not prevent sexually transmitted infections (STIs).

33 How it prevents pregnancyMethodHow it prevents pregnancyBarrier methods Block sperm from reaching the eggSome are used with spermicides, which kill sperm.Fertility awareness (natural family planning)Identifies the time during a woman's cycle when she is most likely to become pregnant (fertile). An additional method or abstinence should be used during this time of fertility.Permanent birth control (sterilization)Men: Vasectomy blocks the release of sperm.Women: Tubal ligation surgery or tubal implants block the movement of an egg through the fallopian tube, preventing fertilization.

38 Termination of early pregnancy---- Artificial abortionSurgical abortionVacuum aspiration<10wMedical abortion<7wSuction aspiration or vacuum curettage, is used in most first trimester abortions. A powerful suction tube with a sharp cutting edge is inserted into the womb through the dilated cervix. The suction dismembers the body of the developing baby and tears the placenta from the wall of the uterus, sucking blood, amniotic fluid, placental tissue, and fetal parts into a collection bottle. Great care must be taken to prevent the uterus from being punctured during this procedure, which may cause hemorrhage and necessitate further surgery. Also, infection can easily develop if any fetal or placental tissue is left behind in the uterus. This is the most frequent post-abortion complication.D&C (Dilatation (Dilation) and Curettage)

39 Induced Abortion syndrome Miss-suction or leakageCommon complicationsComplicationUterine perforation and visceral injuryBleeding in operationInduced Abortion syndromeIncomplete abortionUterine hemorrhageInfectionMiss-suction or leakageCervical and intrauterine adhesionsRegret syndrome(long-term)Beside the death, abortion has other complications, the common complications of abortion include uterine perforation and visceral injury, bleeding, abortion syndrome, cervical adhesions, incomplete abortion, infection, miss-suction, and regret syndrome. I had a patient, she had an abortion three years ago, she wants a baby this two years, but she only had spontaneous abortion two times, infertility for about 1 year. So when I asked her if she regrets the first abortion three years before, she said yes, yes, I always regret the abortion. So the regret syndrome is a seirece long-term complication of abortion.欧加侬3939

40 Medical abortion Overview and history Overview and historyMifepristone was developed during the early 1980s by researchers at the French. While investigating other diseases, investigators discovered that some of the compounds blocked the similarly shaped progesterone receptor. Refinement of the compound led to the production of RU 486, the medication now known as mifepristone.Clinical testing of mifepristone began in Europe in The results from the clinical trials showed that mifepristone, when used alone, induced a complete abortion in 60% of women with pregnancies up to 49 days' gestation. Investigators then discovered that by adding small doses of a prostaglandin analog on the last day of mifepristone treatment, the complete abortion rate increased to over 95%. France became the first country to license the mifepristone/prostaglandin analog regimen for early abortion in 1988

41 Medical abortion Mechanism of actionMifepristone: blocks the action of progesteronecauses the cervix to softenMechanism of action of mifepristoneMifepristone (a synthetic steroid) is an anti-progestin that blocks the action of progesterone, a hormone necessary to maintain a pregnancy. By blocking the action of progesterone, mifepristone alters the endometrium (the uterine lining), induces menstrual bleeding, and causes the uterine lining to shed. Mifepristone also causes the cervix to soften and initiates uterine contractions.Mifepristone is used in conjunction with misoprostol. Misoprostol is an analog of prostaglandin E1. By interacting with prostaglandin receptors, misoprostol causes the cervix to soften and the uterus to contract, resulting in the expulsion of the uterine contents.The medical abortion procedure requiresat least three trips to the abortion clinic. In the first visit, the woman is given a physical exam, and if she has no obvious contra-indications (such as smoking, asthma, high blood pressure, obesity, etc.) we give her the pills.At the second visit which comes 36 to 48 hours later, the woman is given a dose of artificial prostaglandins, usually misoprostol, which initiates uterine contractions and causes the embryonic baby to be expelled from the uterus. Most women abort during the 4-hour waiting period at the clinic, but about 30% abort as many as 5 days later.Misoprostol: causes the uterus to contractcauses the cervix to soften

42 complete abortion >21 daysMedical abortionIs a kind of non operation of artificial abortionCould reduce the fear and pain on the operation of womenLong bleeding time and the potential risk of major bleedingIs the only remedy for contraception failureNot a contraceptive methodvaginal bleedingVacuum abortion<7 daysMedical abortion14-15 days19.2%complete abortion >21 days1.5%emergency curettage0.16%blood transfusionThere are several serious well documented side effects associated with RU 486/prostaglandin abortions, including prolonged severe bleeding, nausea, vomiting, pain, and even death. At least one woman in France died while others had heart attacks from the technique. In U.S. trials conducted in 1995, one woman is known to have nearly died after losing half her blood and requiring emergency surgery. So we must keep in mind, medical abortion may induces heavy bleeding, which my need emergency curettage.

45 Figure 1a. Mirena and inserterFigure 1b. Aligning the arms with the slider in the furthest positionLoading Mirena into the insertion tubeProperly loaded Mirena with knobs closing the end of the insertion tubeThreads are secured in the cleftSetting the flange to the uterine depthAdvancing insertion tube until flange is 1.5 to 2 cm from cervical osPulling the slider back to reach the markReleasing the arms of MirenaMirena in the fundal positionReleasing Mirena from the insertion tubeCutting the threads